Two Cases of Malignant Dis- 
ease : An Osteosarcoma in- 
volving an Anterior Cranial 
Fossa, and an Epithelioma of 
the Larynx. 
CHARLES PHELE^ M.D., 
Surgeon to Bellevue and St. Vlncent'i Hospitals 
REPRINTED FROM THE 
Neto ¥ork JjHeUtcal ^Journal 
for June 33, 189f Reprinted from the Few York Medical Journal 
for June 23, 189 f 
TWO CASES OF MALIGNANT DISEASE: 
AN OSTEOSARCOMA 
INVOLVING AN ANTERIOR CRANIAL FOSSA, 
AND AN EPITHELIOMA OF THE LARYNX* 
By CHARLES PHELPS, M. D., 
SURGEON TO BELLEVUE AND ST. VINCENT'S HOSPITALS. 
In December last I presented to this society an intra- 
peritoneal sarcoma which was of more than usual interest 
in its origin and development. The operation was im- 
mediately successful, and I have not at the present time 
been advised of its recurrence. I propose now to submit 
two other cases of malignant disease which, though differ- 
ing from the first and from each other in type, have a 
character in common, in virtue of which they may be con- 
sidered closely enough connected to form at least a harle- 
quin series. 
A Case of Osteosarcoma involving an Anterior Cranial 
Fossa.-The patient, sixty-five years of age, was admitted to 
Bellevue Hospital in June, 1892, for relief of a pain in the left 
eye and frontal region. Ten months previously she had been 
* Read before the Society of Alumni of Bellevue Hospital, April 4, 
1894- 
Copyright, 1894, by D. Appleton and Company. 2 
TWO CASES OF MALIGNANT DISEASE. 
knocked down, and, her forehead striking the floor, a persistent 
swelling over the left eye ensued, which gradually hardened, 
increased in size, and became moderately painful. In time it 
was followed by protrusion of the eye and lacrymation. Her 
general health was good and her previous history unimport- 
ant. 
At the time of admission the eye was markedly protruded, 
but there was no evident change in its structure; sight was 
unimpaired. Ophthalmic examination disclosed slight optic 
neuritis. The osseous tumor was situated just above the ex- 
ternal portion of the supra-orbital ridge; it was hard, painful 
on pressure, circular in form, about an inch and a half in diame- 
ter, and elevated above the surrounding surface about a half to 
three quarters of an inch at its highest point in the center. 
The skin which covered it was uninvolved. Its growth was very 
perceptible during the week's time in which it remained under 
observation. 
In operation a semicircular incision was made from a point 
over the junction of the inner and middle thirds of the supra- 
orbital ridge to the temporal fossa, and the underlying portion 
of the frontal bone exposed. This flap, with the eye and ap- 
pendages, which were partially detached from the orbit, was 
turned over upon the cheek. The external table of the bone cov- 
ering the tumor was thickened, softened, and eroded, and its mar- 
gin well defined. A canal was then cut through the adjacent 
healthy bone, which was of unusual thickness-at least half an 
inch by actual measurement. A small trephine, Hay's saw, and 
rongeur were employed for the purpose. The orbital ridge in- 
ternally and the malar process and zygoma externally were 
sawn through and the superior wall of the orbit exposed and 
cut. An attempt was made to lift out the mass by means of a 
curved periosteal elevator, which was successful only in remov- 
ing its superficial portion; the remainder was subsequently ex- 
cavated by the same instrument. 
The operation, which presented no special difficulties, was 
completed in a little more than an hour's time. There was no 
loss of blood except a small amount from the tumor itself at one 
point at an early stage of the procedure, and which was readily TWO CASES OF MALIGNANT DISEASE. 
3 
controlled by a temporary compress of gauze applied beneath 
the margin of the osseous incision. No stimulant was required 
and the patient did not suffer from subsequent shock. 
The cavity which remained showed a loss of almost the en- 
tire upper and inner walls and a portion of the outer wall of 
the orbit, including the lacrymal bone and portions of the frontal 
sphenoid and ethmoid bones which had been incorporated in 
the process of growth. The tumor, apparently beginning in the 
diploe of the ascending frontal bone, had destroyed a great part 
of the external and all the inner table in the region where it had 
first appeared above the eye. It had then extended quite to 
the median line behind the orbit and beneath the frontal lobe 
of the brain. The dura mater was not involved and was unin- 
jured in the course of operation. The whole left frontal lobe 
was exposed anteriorly and inferiorly, and could be seen to be 
compressed and pushed backward almost to the petrous portion. 
The tumor was of irregular form, and from two to three inches 
in its longest diameter. It was largely composed of bone in 
lamellae and tubercute, which were in great part eburnated. It 
was friable, but little vascular, and in its soft parts of cheesy ap- 
pearance. A subsequent microscopic examination by Dr. J. W. S. 
Gouley showed it to be spindle-celled, with a small proportion 
of round cells intermixed. The adjacent muscular and con- 
nective tissue were infiltrated with the round cells. At the 
first dressing of the wound on the second day there was copious 
haemorrhage, which seemed to be capillary and was readily con- 
trolled. Vision and ocular movements were both undisturbed, 
and there had been no elevation of temperature. At the end 
of ten days she became delirious, with lucid intervals, and com- 
plained of headache and photophobia. About this time she had 
two attacks of severe vomiting, followed by unconsciousness 
and apparent collapse. The condition of the wound, however, 
continued to be satisfactory, and the temperature at no time 
exceeded 100° F. Ten days later still the wound was almost 
entirely healed, and a plate of new bone covered in the cavity 
left after operation. Active delirium had ceased, but her mind 
was still unbalanced. She had some delusions, talked much to 
herself, was childish in her manner, and still complained of head- 4 
TWO CASES OF MALIGNANT DISEASE. 
ache. At the end of a month there were no symptoms, either 
general or local. She was discharged from the hospital three 
months after the operation. The movements of the eye were 
unimpaired, and its structure and function were normal. There 
was no evidence of a recurrence of the disease. A thick, firm 
plate of new bone replaced the osseous structures removed, 
This presented a plane surface, as no effort had been made to 
preserve the frontal convexity, but no considerable deformity 
resulted. 
Nothing occurred to attract the patient's attention to herself 
till December (six months), when she noticed a slight bulging 
of the eye, which was somewhat sensitive to the touch, and she 
began to suffer pain in the median line of the forehead. A 
little later she discovered a slight and very hard supra-orbital 
swelling, which, in six weeks' time, extended to the outer 
angle of the eye and over the malar bone. In March the swell- 
ing became less well defined and reached the temporo-parietal 
region. Vision was unaffected. She was readmitted to the 
hospital in April, 1893. At this time her general health had 
become seriously impaired. The frontal bone, at the inner mar- 
gin of the former incision, was thickened and nodular. The 
tumor in the temporal region had increased and had softened so 
much as to give the impression of a cyst. The eye protruded, 
the conjunctiva was somewhat inflamed, and vision was a little 
clouded. She was feeble and anaemic, but her condition suffi- 
ciently improved in the course of a week to justify the attempt 
to again extirpate the tumor. Incision was made to circum- 
scribe the cicatrix of former operation, beginning at the inner 
angle of the eye, carried well up toward the coronal suture, and 
terminated over the zygoma. The flap was dissected down- 
ward through the orbit, and with the eye, which was held only 
by the optic nerve and vessels, turned over upon the face, as in 
the original procedure. The frontal plate of new bone was cut, 
and the supra-orbital ridge at its inner extremity and the zygo- 
ma externally sawn through. The tumor was then removed in 
fragments by the bone forceps and the fingers. The dura was 
involved on the inferior cerebral surface, and at one point was 
torn away, exposing the brain tissue. The frontal lobe was less TWO CASES OF MALIGNANT DISEASE. 
5 
compressed than at the time of previous operation, and occupied 
about half of the anterior fossa. The portion of old frontal 
and ethmoid bone which had become implicated in the renewed 
progress of the disease was cut away. The new osseous growth, 
which had replaced the ascending frontal and orbital plate pre- 
viously resected, was included in the mass removed. The pres- 
ent growth, unlike the original-which was dry, white, and 
cheesy, with osseous lamellae-was composed of delicate bony 
reticulae, filled with soft and vascular tissue. Haemorrhage was 
moderate, there was no shock, and strength was quite main- 
tained by stimulants hypodermically administered during the 
operation. On the second day the conjunctiva and lids were 
somewhat oedematous, but vision was unimpaired. The optic 
nerve and retina, upon examination, were found to be much 
congested. On the fifth day some dysphagia and some rigidity 
of the right arm, which increased and then diminished, were 
noticed. Six hours later there was a slight convulsive move- 
ment of the whole left side of the body, and at about the same 
time a slight right facial paralysis was evident. Incontinence 
of urine and faeces followed. The left eye, which had become 
more protuberant, began to pulsate, and the cavity of the wound 
was found to be filled with brain substance. On the sixth day 
there were slight convulsive movements of the left side, with 
the general condition unchanged. On the seventh day the tem- 
perature increased (to lOd'fi0), the pulse became rapid, and respi- 
ration irregular and shallow. She died six days and seven hours 
after operation, having been unconscious for sixty hours. 
Necropsy was denied. The wound was reopened, however, 
and the cavity left by removal of the tumor was found to be 
filled with diffluent brain matter, into which numerous minute 
haemorrhages had occurred. No foreign growth could be dis- 
covered in any part of the brain or cranial cavity which could 
be reached. 
I have detailed this case with some minuteness because 
it seems to me of more than ordinary importance. The 
development of the tumor as a result of traumatism, its 
situation which came to be largely within the cranial cavity, 6 
TWO CASES OF MALIGNANT DISEASE. 
the facility with which it was removed, and the apparent 
interval which elapsed before its recurrence, are alike 
worthy of note. The occasional origin of this form of 
malignant growth in traumatism is clearly illustrated, and 
the comparatively long period during which it seemed to 
be latent, although the adjacent tissues were infiltrated 
with small cells, is calculated to afford some confidence in 
operation even after the disease has made considerable 
progress. 
Though the growth had its beginning in the diploe of 
the frontal bone, and was consequently originally extra- 
cranial, it was essentially intracranial at the time of opera- 
tion and came within the province of that department of 
surgery. The method of procedure adopted demonstrates 
an easy means of access to the anterior portion of the 
cranial cavity for its complete exposure. The preservation 
the eye and its appendages with entire integrity of func- 
tion, and the reproduction of the frontal bone removed, 
obviate possible objections to its use. 
The continued freedom of the brain from implication 
seems remarkable. For at least ten, and probably the 
greater part of twenty, months the dura had resisted the 
extension of the morbid process inward, though bone and 
connective tissue yielded. At the secondary operation the 
dura was found to be incorporated in the tumor over a very 
limited space, not larger than a finger nail. This was not 
from any inherent power of resistance, since in Hale White's 
collation of brain tumors sarcomata were more numerous 
than any others, save those of tubercular character, and some 
were of dural origin. Death finally resulted directly from 
brain lesion, but the sarcomatous growth was only con- 
cerned in so far as it induced fatal nutritive disorders. 
Time only permits this very casual mention of matters 
which might properly deserve more careful consideration. TWO CASES OF MALIGNANT DISEASE. 
7 
A Case of Epithelioma of the Larynx.-A gentleman of dis- 
tinction in the medical profession, during a paroxysm of cough- 
ing three years ago, felt a rupture occur in the larynx and was 
aphonic from that moment until his death, though he suffered 
no other local inconvenience, and his general health until very 
recently remained unimpaired. In October, 1892, at my sug- 
gestion he consulted a specialist in diseases of the throat, who 
discovered a growth upon the left vocal cord which was of 
■warty appearance and covered nearly its whole extent. He 
was assured that its character was benign and need cause him 
no uneasiness, but that he might return for further examination 
after some months. 
In December last I visited him at his request. He had then 
been confined to his house since the first of the month, and 
thought he was suffering from the then prevailing epidemic of 
influenza. He was physically weak, mentally indisposed to 
exertion, and had some laryngeal cough. I subsequently 
learned that for some months he had subsisted mainly upon 
fluid food on account of a difficulty in deglutition, and had 
failed in nutrition. I attributed his condition to progress of 
the laryngeal tumor, and again suggested examination by a 
laryngologist. He was seen by Dr. 0. C. Rice, who confirmed 
my suspicion that the disease was malignant, and coincided in 
my opinion that early tracheotomy should be done. In the 
early morning of December 31st the trachea was opened, partly 
on account of increasing dyspnoea, but more hastily by reason 
of the unfavorable character of the pulse. He derived immedi- 
ate advantage from this preliminary operation, which was soon 
lost by the considerable formation and extrusion through the 
tube of masses of tracheal granulation tissue. These con- 
tained aggregations of small spindle cells which were regard- 
ed as suspicious. On the 8th of February the larynx and 
trachea were opened externally in the median line from the 
thyreoid notch to the tracheal opening previously made. The 
tumor, which nearly filled the larynx, was cut away by scissors 
and its site curetted and afterward cauterized with chromic 
acid. The tracheal granulations were removed in the same 
manner. This operation, like the previous tracheotomy, was 8 
TWO CASES OF MALIGNANT DISEASE. 
done with the use of cocaine and presented no difficulties, ex- 
cept in the control of some troublesome haemorrhage from a 
small vessel at the posterior commissure of the vocal cords, 
which was finally effected by the fortuitous application of 
clamps which were left in situ overnight. I was assisted by 
Dr. Gouley, Dr. Rice, Dr. Wiggin, and Dr. D. II. Cooke, to 
whom I beg to acknowledge my indebtedness. He suffered 
little from reactive effects of the operation. At the end of the 
first week there was very temporary tenderness of the thyreoid 
cartilage, painful deglutition, and discharge from the mouth of 
mucus tinged with blood. This condition, after an interval of 
comparative comfort, was followed by profuse muco-purulent 
discharge from the tube, renewed formation of granulation 
tissue, and gradual occlusion of the trachea. He was freely 
nourished, moved about his apartment, and maintained a reso- 
lute and cheerful condition of mind. At the end of the second 
week his strength had visibly failed, his lungs were passively 
congested, his respiration was becoming less sufficient, and he 
was delirious at night. On the day of his death he was unusu- 
ally cheerful in the morning, ate his luncheon, smoked a cigar, 
and only began to suffer markedly from dyspnoea in the early 
evening. At eight o'clock, after two hours of delirious dyspnoea, 
he became unconscious. His breathing was afterward easy, and 
his pulse fairly strong, quite regular, and not more than a hun- 
dred in the minute. He remained eight hours in this condition 
without appreciable change, when he died somewhat suddenly 
on the seventeenth day after operation. 
The tumor was very carefully examined by Dr. Gouley and 
by Dr. E. K. Dunham, of the Carnegie Laboratory, who con- 
curred in the opinion that it was a commencing epithelioma. 
The sections made showed a stroma of fibrous tissue covered 
with stratified epithelium and containing nests of epithelial cells, 
many of which included "pearl bodies." From independent 
observations both gentlemen reached the conclusion that the 
process of degeneration had not extended over more than from 
three to four months. 
If the direct influence of traumatism manifest in the 
preceding case of osteosarcoma, and possible in the earlier TWO CASES OF MALIGNANT DISEASE. 
9 
one of intraperitoneal sarcoma, is absent in the history of 
this case of epithelioma, it was still exerted in the forma- 
tion of the original papilloma. There seems little doubt 
that an injury of the vocal cord sustained during a parox- 
ysm of coughing occasioned the benignant growth which 
later suffered degeneration. 
The lengthened period during which this primary forma- 
tion, though in continued process of growth and exposed to 
continued irritation, resisted its own inherent tendency to 
retrogression, to which it eventually succumbed, not only 
points the danger of the expectant, or rather drifting 
method of treatment, but is reassuring evidence that even 
in long-neglected cases a late operation, though in this in- 
stance it was unhappily a little too late, may yet chance to 
be in time. 
It may be noted that the period during which degenera- 
tion is supposed to have begun embraces the time when the 
general health first distinctly failed. It is, of course, im- 
possible to determine whether this coincidence has any 
significance, but it is a fact which naturally arrests atten- 
tion. 
The moral of these two later cases, as well as of the one 
which went before, seems to be the same : that safety only 
lies in the earliest possible removal of all tumors, whether 
benign or malignant. As all tumors, whatever their begin- 
ning, are liable to end in malignancy, and as the exact time 
when benign growths may be destined to transformation 
can not be predicted, so none can tell in how brief a time 
delay may become disastrous. If this moral seems trite to 
many members of this association, I beg them to remember 
that it is among the truths which still require reiteration, 
for it is still far from universal acceptance as a guide in 
practice. 
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